Barriers Towards Obstetric Care Service Utilization in Ethiopia: An Explorative Qualitative Study

Background Obstetric care has been at the center of both global and national agendas. More than 50% of pregnant mothers are still preferring to give birth at home with some even after having full antenatal care. However, a few literatures looked at contributing factors for this problem but they are not conclusive and do not consider different sociocultural context of Ethiopia and different health service related barriers. Hence, the aim of this study was to explore barriers to obstetric care service utilization in Ethiopia using the socio-ecological model. Methods Explorative qualitative study was employed involving key-informant interviews, in-depth interviews, and focus group discussions between October and December 2021; Individual, community, health system, and contextual barriers were explored. Atlas ti. Version 9 was used for analysis. Result Lack of awareness, unfavorable perception, lack of partner involvement, cultural barrier, shortage of supplies, poor infrastructure, provider-related factors, poor monitoring, and evaluation system, challenging topography, and conflict were the major barriers that hinder mothers from receiving obstetrics service in Ethiopia. Conclusion Lack of awareness, unfavorable perception, conflict, problems with health system structure and process, and cultural and geographical conditions were major barriers in Ethiopia. Therefore, packages of intervention is important to avail essential equipment, strengthening follow up system, create awareness, and increase access to health facilities is very important for service improvement by the government and non-governmental organizations. Additionally, implementing conflict resolution mechanism is important for addressing better obstetric service.


INTRODUCTION
Obstetric care encompasses the provision of care to pregnant women throughout the stages of pregnancy, labor, and the postpartum period.This care is delivered by skilled health professionals who have received appropriate training and can be accessed at various healthcare facilities (1).Its primary objectives include identifying and managing risks, preventing diseases, and promptly addressing any danger signs.Additionally, obstetric care offers pregnant women the opportunity to acquire knowledge about healthy behaviors, reduces the risk of mother-to-child HIV transmission, and provides access to services during and after pregnancy (2).
Skilled birth attendance, a crucial component of obstetric care, has demonstrated its ability to significantly reduce maternal deaths, accounting for more than three-fourths of the decline.This intervention is widely regarded as the most critical measure for reducing maternal mortality (3).Nevertheless, the availability, effectiveness, and utilization of obstetric care in developing countries are influenced by a multitude of factors, both health-related and nonhealth-related.These factors contribute to the occurrence of preventable maternal and newborn deaths.According to the World Health Organization, approximately 810 per 100,000 women in low-and middle-income countries (LMICs) die every day due to avoidable causes associated with pregnancy and childbirth (4).Consequently, each stage of obstetric care plays a pivotal role in mitigating the unacceptably high rates of maternal and newborn mortality in LMICs.
Sexual and reproductive health and rights in general, and obstetric care specifically, have been at the center of both global and national agendas.There were several global initiatives and goals set to improve obstetric care such as safe motherhood, the millennium development goal, and the recently sustainable development goal (SDG); regrettably, only five countries achieved the millennium developmental goal (MDG5) (improve maternal health) with wide geographic inequities in overall performance (5).The SDG in its goal three aims to ensure healthy lives and promote well-being for all people of all ages.However, the recent global pandemic has already hampered efforts, forcing us to assess possibilities with assumptions such as the SDG push scenario, COVID baseline scenario, and high damage scenario, each showing less probability of meeting the goal (6).In Ethiopia, reproductive health with a greater focus on obstetric care has been on the agenda for the last two decades (7)(8); it is worth noting that a policy analysis reported that the nation's maternal and child health policies failed to elucidate plans to implement and monitor the proposed interventions and ended with a strong suggestion to focus on equity (9).
Between 2000 and 2016, Ethiopia saw a significant drop in maternal mortality, going from 871 deaths per 100,000 live births to 412 deaths per 100,000 live births, but still far higher than the global average (10,11)(12).More than 50% of pregnant mothers are still preferring to give birth at home with some even after having full antenatal care citing reasons such as poor quality of care, cultural reasons, and disrespectful and abusive care among others (13-16).However, few looked at demand-side barriers and almost none looked at the national level.Hence, this study attempted to explore the demand side view of barriers to the utilization of obstetrics care in Ethiopia.

Study setting and design:
The study was undertaken in four regions of Ethiopia namely Amhara, Oromia, Southern Nations and Nationalities of Peoples' (SNNP), and Sidama regions between October and December 2021.To address the objective of this study an explorative qualitative study was employed by involving key-informant interviews, in-depth interviews, and focus group discussions.Participants: Maternal and child health (MCH) case team leaders, health extension workers (HEWs), regional, zonal, and Woreda health office (WoHO) level reproductive maternal and nutrition and child health (RMNCH) experts were participants for key informant interviews (KII).Pregnant mothers and home delivered mothers were participants for the study in-depth interview (IDI).Focus group discussions (FGDs) were conducted with community leaders (women's development team (WDT), religious and kebele leaders, traditional healers, and traditional birth attendants), and hospital quality leaders or members.Sample size and sampling: Study participants were selected in consultation with regional health bureaus, respective WoHO and HEWs.For the key-informant and in-depth interview, participants were selected using a maximum variation sampling.In maximum variation sampling, participants' selection is often made using pre-set criteria to ensure the inclusion of as many variant observations as possible.These variations can result from variations in the demography of the participants or the phenomenon.In this study, maximum variations were achieved by including participants from different geographical locations (it was conducted in different regions of Ethiopia), age groups (from adolescent to elderlies), gender, and role in the community and health facility.FGD participants were purposively selected in the community.The sample size was determined by the level of saturation of the collected information.A total of 41 participants (regional RMNCH directors, woreda RMNCH coordinators, Primary Health care unit (PHCU), and MCH case team leaders) participated in the KIIs, whereas 32 people participated in the IDIs (15, 5, 6 and 6 at SNNP, Sidama, Oromia and Amhara regions, respectively).A total of 13 FGDs (4 at SNNP, 3 FGD at each Sidama, Oromia and Amhara regions) were undertaken considering agrarian, rural, and urban places and male to female equal participation were also considered.Because of the cultural sensitivity of the SRMH services, clients who participated in IDI did not participate in the FGD.Data collection Tool and procedure: Pre-tested key-informant, in-depth interview, and focus group discussion guides were used for collecting relevant data.The tools were developed to identify barriers of obstetric care service utilization in Ethiopia.The interview guides were categorized into four main themes of the socio-ecological model; namely, individual, community, health system, and contextual level barriers and different questions related to the sub-themes were asked with different probing mechanisms.In consultation with regional health bureaus 19 woredas from 5 zones of SNNP region, 9 woredas from Sidama region, 10 woredas from 4 zones of Amhara region and 8 woredas from 2 zones of Oromia region were selected purposively.Health facilities were also selected by WoHO.Community leaders and IDI participants were also selected purposively in collaboration or consultation with HEWs and respective WoHO.During the selection process different age category, from adolescent to elderly, and equality of male to female distribution were considered.All woredas were classified in to three sections, high performing, medium performing and low performing then all KIIs, IDIs and FGDs were conducted proportionally.Data Quality Assurance: Training had been provided to data collectors and supervisors about the purpose and content of the tools before the data collection.A pre-test was undertaken in woredas of all regions' other than the actual data collection area before the actual data collection started.Close follow-up by the research team and supervisors was undertaken, and feedback was also given on the completed forms for the data collectors before the next data collection day.A quality check was done after transcription to check the consistency of the transcription with the recorded audio and way of writing.The quality of the verbatim transcriptions and translations was assessed by a team of experts.Data management and analysis: For analysis, the data were transcribed and then translated into English.To clarify issues, field notes were added to the transcripts.Researchers read the transcripts before beginning coding and writing them up.The pre-defined codes were used to get a complete picture of the data.Atlas ti.version 9 was used to evaluate the qualitative data using a thematic content analysis approach using a socioecological model.Ethical consideration: Ethical clearance was obtained from the Institutional Review Board of Hawassa University, College of Medicine and Health Sciences.An official permission letter was obtained from the regional health offices, WoHO, and health facilities, respectively.Official permission was also sought from the selected health facilities.After confirmation to participate in the study, written informed consent was obtained from participants.Personal privacy was maintained by interviewing the interviewee alone and identifications like names were not used in the questionnaire.Participants were also assured that their participation, nonparticipation, or refusal to answer questions did not affect their personal lives.

Socio-demographic characteristics:
The participants' age ranged from 19 to 68, and their level of education ranged from being able to read and write up to have a degree (table 1).Barriers to maternal obstetrical service utilization: Utilizing a socio-ecological model, barriers to women's obstetrics service uptake were compiled into four main themes: individual, community, health system, and contextual level (Fig. 1).
Fig. 1: Socio-ecological model that become barriers in utilizing Maternal obstetrics services in Ethiopia, 2021.Similarly, most participants also mentioned that poor linkage between PHCU and HP affects obstetrics service uptake which is mainly due to problems with access to road.

Individual level barriers
"The linkage between the health center and health post and monitoring and evaluation was so poor.The health professional who went to support HEW for monitoring and support, in general, have huge knowledge and skill gap.In addition, there are remote HPs which didn't have road access so in those places cascading the monitoring and supervision process is so hard.Some health centers didn't have a motor bicycle and they go up to 12 km on foot to support one HP." [42 years KII participant, Sidama region] 4. Context related barrier Conflict/instability: Most of the participants especially from the Amhara region and pastoral parts in the SNNP region stated that onset of conflict was their major barrier to obstetric service uptake.Home delivered mother also explained that conflict causes a huge barrier to accessing transportation and ambulance to get obstetrics services. "

DISCUSSION
Barriers of maternal obstetrics health service utilization was explored by this study.Lack of awareness, unfavorable perception, lack of partner involvement, cultural barrier, shortage of supplies and poor infrastructure, provider related factor, poor monitoring and evaluation system, challenging topography and conflict were the main barriers of obstetric care service utilization which were presented using socio-ecological mode.
A pregnant women should have adequate knowledge about when and where to get obstetrics services which help her to start receiving the care early and increase maternal and child health (17).In line with this our study also explored that the main barrier to receive antenatal care is lack of awareness about when and where to start the care.Additionally, most of KII participants stated harmful cultural beliefs and practices were affecting the uptake of obstetric service which is mainly due to lack of awareness by the community in general.This finding also in line with the study done in other parts of Ethiopia (18,19).In Ethiopia like other developing countries most of decision making is handled by males.They do have great role especially on obstetrics health service utilization (20).This study also identified that male involvement increases maternal health service utilization but in some parts of the country do not want to go with their wife to the health facility.Similarly, different studies also stated that partner involvement have great role in maternal health service utilization (21,22).
Participants also mentioned that shortage of supplies, poor infrastructure and closing of health posts (HPs) affect obstetrics service utilization.This finding also similar with other studies done in other parts of Ethiopia(18,23,24).This is due to the fact that lack of equipment, having poor infrastructure and closing of health facility are categorized under third delay, which is the major contributing factor for maternal mortality (25,26).
Respectful maternity care is very mandatory during providing maternal obstetrics care because disrespecting and abusive care prevents mother from receiving future utilization (27).In line with this our study also reviled that lack of respectful care is another barrier for service utilization.Providing abusive care might be liked to lack of trained staff which is in line with our study and this finding is also in line with other studies done in other parts of Ethiopia (28,29).
Monitoring and evaluation is a strategy that is very important to maintain quality of health service provision, which have effect on service uptake (30).Strong monitoring and evaluation system have effect on increasing the skill of the health care provider, motivate the health workers, increase resource allocation and strengthening implementing standard procedures.Study participants of this study also mentioned that poor monitoring and evaluation system is one of the barrier in obstetric service uptake (31).Mother and children health was primarily affected during conflict period this is because it severely compromises health care delivery (32).It is known that in Ethiopia the conflict which was raised from the Tigray region was expanded to adjacent regions, Amhara and Afar, which causes significant effect on the health care delivery (33).Our study also demonstrated that due to conflict mothers could not get appropriate obstetric service even though they are in need.This study also reviled that challenging distance or topography from the health facility is also barrier which prevents mother from acquiring maternal health service uptake (34).Participants of this study also mentioned that challenging topography and far distance from health facility increases home delivery.Even though the Ethiopian government launched a new innovating approach called maternal waiting home based on WHO recommendations to alleviate this problem, there is no sufficient food for pregnant women due to lack of budget(35).So, the problem is becoming a huge barrier.
In conclusion, different levels of barriers were identified through this study.
Lack of awareness, problems with health system structure and process, conflict, and cultural and geographical conditions were major barriers in Ethiopia.Therefore, to alleviate these barriers the federal government should work strongly to manage raised conflicts in respective areas.The federal ministry of health in collaboration with other supporting governmental and nongovernmental organization equip the health facilities and trains human resources.Regional health bureau, Zonal, and district level health offices should strongly work on increasing the community's awareness to decrease cultural beliefs and increasing accessibility of health facilities by strengthening maternal waiting rooms and through alternative ways.We also recommend implementing conflict resolution mechanisms and peace building are important for addressing better utilization of obstetric services.

Table 1 :
socio-demographic characteristics of participants for barriers to obstetrics health service utilization in Ethiopia, 2021.
Note: KII: Key informant interview, IDI: In depth Interview